2013_0103 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: 1 I M
PWS I.D. #
A
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer ' ; _) Size
Model Number A Located At
Serial Number
The above is certified to be true.
Firm Name �� Certified Tester
Firm Address Cert. Testa No. Date
Gauge # - c:° F 1-, A n %
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Tight ❑
RP-�psid
Leaked ❑
-psid
psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Name �� Certified Tester
Firm Address Cert. Testa No. Date
Gauge # - c:° F 1-, A n %
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy